CROSS Act Individual Application for Assistance

Coronavirus Relief One-Stop Shop (CROSS) Act 2020

Individual (Non-Employer) Application for Assistance Office of the Minister of Finance I Ruth S. Wong Professional Building, Meyuns I 488.6968 I crossrelief@palaugov.org

PERSONAL INFORMATION

Last First MI Age Nationality Gender

Date of Birth

SS Number E-Mail P.O. Box Contact Home:

Cell:

Name of Employer (on W-2 or Pay Check) Employer Phone

Name of Immediate Supervisor

Employer E-Mail Address:

Your Position with Company Length of Employment

Status of Employment (Check One)

Full-Time Part-Time

# of Hours Worked Per Week on Regular Schedule

# of Hours Worked CURRENTLY, on Reduced Hours Schedule

If currently not working, please indicate reason for stoppage (e.g. Lay-Off)

Hourly Rate of Pay Monthly Salary Type of Assistance Requested (please check one or more boxes applicable to you):

Temporary employment or transfer (non-citizen

Temporary Employment (citizen)

Unemployment Stipend

Access to Lifeline Utility Subsidy

If seeking temporary employment, when can you start work?

Do you have any medical condition(s) that may prevent you from performing select tasks? Yes No

If yes, please list condition(s): AUTHORIZATION

I, (PRINT NAME) ________________________________, authorize the Ministry of Finance to access any record regularly

kept by the Ministry of Finance, Ministry of Justice, Social Security Administration, Health Care Fund, WIOA Office, and

the Palau Public Utilities Corporation for the purpose of confirming information submitted on this form and to assess

my qualification to apply for temporary relief under the Coronavirus Relief One Stop Shop (CROSS) Act.

I certify, swear and attest that the information submitted herein is true and accurate to the best of my knowledge or belief, and consistent with the records available to me. _________________________________________ Signed & Sworn Before Me: __________________________________ Applicant Signature Notary Public

REQUIRED SUPPORTING DOCUMENTS Citizens Non-Citizens

Check Stubs from December 2019 – April 2020 Check Stubs from December 2019 – April 2020

Copy of Valid Government Issued ID Card Copy of Valid Work Permit

Copy of Social Security Card Copy of Social Security Card

Notice of Lay-Off/Reduction of Hours from Employer (if available)

Notice of Lay-Off/Reduction of Hours from Employer (if available)